Strategies to reduce duration of untreated psychosis

The theme for World Mental Health Day 2018 is “Young People and Mental Health in a Changing World”. One way to transform the lives of young adults presenting with psychosis is to shorten the duration of untreated psychosis (DUP), explained John M. Kane, Professor of Psychiatry, Northwell Health, NY, in an inspiring plenary at IEPA 11. He presented evidence showing that team-based coordinated specialty care programs for young adults with first episode psychosis improve quality of life, particularly for those with a DUP less than 74 weeks. He also discussed some of the difficulties associated with adherence to oral antipsychotic treatment regimens, and how long-acting injectable antipsychotics may help to further improve outcomes and prevent relapse.

NAVIGATE is a team-based program for implementing coordinated specialty care (CSC) within the Recovery after an Initial Schizophrenia Episode – Early Treatment Program (RAISE-ETP), explained Professor Kane.

Many patients with early psychosis might benefit from changes to their psychotropic medication

RAISE-ETP enrolled 404 people aged up to 40 years who had a psychotic disorder and had been treated with antipsychotics for less than 6 months. On entry, it was considered that almost 40% might benefit from one or more changes to their psychotropic medication.

The NAVIGATE program is based on shared decision making and focuses on strength and resiliency (in contrast to pessimism and limitations). Its four components are psychopharmacology, individual resiliency training, family psychoeducation and supported employment and education.

CSC improves functional and clinical outcomes

Professor Kane and his colleagues carried out a randomized clinical trial (RCT) to compare NAVIGATE with community care in 34 local clinics in 21 US states over 2 years: 17 sites provided NAVIGATE to 223 participants and 17 sites provided community care to 181 participants. The outcomes were assessed by experts working remotely, and the primary outcome was quality of life.1

Coordinated specialty care is more effective in patients who have a shorter duration of untreated psychosis

The average age of participants in both treatment groups was 23 years and those who took part in the NAVIGATE program were:

The effects were more pronounced for those with a duration of untreated psychosis (DUP) of less than 74 weeks, said Professor Kane.1

Early intervention services (EIS) benefits patients with early psychosis — but who will fund it?

The results of the RCT have been supported by a 2018 systemic review and meta-analysis. Early intervention services (EIS) were found to be superior to treatment-as-usual (TAU) for early phase psychosis across all analyzable outcomes.2

These studies highlight the need for funding EIS because team-based therapies are generally not reimbursed in the US, said Professor Kane. He added that cost-effectiveness and patient-centered outcomes need further investigation.

Long acting injectable antipsychotics can help addressing the high relapse rate

The relapse rate for psychosis is high and ranges from 16% at 1 year to 82% at 5 years.3

Stopping medication is the most powerful predictor of relapse

The risk of a first or second relapse is approximately five times greater when not taking medication,3 said Professor Kane; and antipsychotic medication has been shown to benefit patients with schizophrenia.4

He suggested that the importance of medication for preventing relapses is generally not recognized even though two to three relapses early in the course of a psychotic illness can erode life opportunities.

Destigmatizing nonadherence can improve adherence

Professor Kane advocated destigmatizing antipsychotic nonadherence. He said that it is human nature to have difficulty adhering to treatment. He added that unidentified nonadherence may lead to unnecessary changes in antipsychotic medication and dose and may result in an inaccurate diagnosis of treatment-resistant psychosis.

Long acting injectable antipsychotics are proving superior to oral antipsychotics,5,6 Professor Kane said, and because they are only administered occasionally, they address difficulties with adherence and can improve outcomes.

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